💬 Enrolment SMS:
Once the patient has accessed the link, they will be prompted to enter their date of birth in order to access the questionnaire 📆
Questions
1. Do you know the name of the contraceptive pill you want?
Yes
No
No, but I want the same one I was given last time
(If Yes)
2. What is the name of the contraceptive pill you are requesting a repeat prescription for?
Type your answer here
(If No/No, but I want the same one I was given last time and when they have answered the last question for yes)
3. Have you been diagnosed with any new health conditions since we last issued you a prescription for the Pill?
These could be any conditions but in particular: heart disease, stroke, breast cancer, liver disease
Yes
No
(If Yes)
4. What new health conditions have you been diagnosed with since your last prescription?
Type your answer here
5. Have you started taking any new regular medications or health supplements recently?
This includes medications prescribed privately (e.g. weight loss treatments) and over the counter medications or supplements (e.g. St John’s Wort)
Yes
No
(If Yes)
6. What are the names of the medications or health supplements that you have started taking since your last prescription?
It’s important to know about other medication or supplements you are taking in case they interact or interfere with your current medication.
Free text
7. Have you experienced any changes to your bleeding pattern that are worrying you (such as unexpected spotting, or after sex)?
It is normal for the mini-pill to cause periods to become irregular, stop or last longer, but it is important that you let us know know if there has been changes that concern you such as bleeding after sex.
Yes
No
8. Are you up-to-date with your cervical screening (smear test)?
Yes
No
9. Are you interested in having any sexual health screening?
This could be important as the oral contraceptive pill does not protect against sexually transmitted infections.
Yes
No
10. What is your smoking status?
Current Smoker
Ex-smoker
Never smoked
(If a current smoker or ex-smoker)
11. How much do you smoke? / How much did you smoke
<1 cigarette or equivalent per day
1-9 cigarettes or equivalent per day
10-19 cigarettes or equivalent per day
20-39 cigarettes or equivalent per day
40+ cigarettes or equivalent per day
12. Are you able to provide a blood pressure reading?
To safely prescribe the contraceptive pill, it is important that we have an up-to-date blood pressure reading
Yes
No
(If yes the questionnaire provides the following information)
Before you take your blood pressure reading:
Sit down comfortably for 5 minutes.
Wear loose-fitting clothing
Make sure your arm is around the same level as your heart
Make sure your arm is relaxed
When taking your blood pressure:
Put the cuff on following the instructions which came with your blood pressure monitor.
Keep still and silent.
Other Tips:
Take at least three readings, each two minutes apart.
Your first reading may be much higher than the next readings. If this is the case, keep taking readings until they level out and stop falling. Use this as your reading.
Please seek urgent medical attention if you develop any of the following:
Blood pressure is 170/115 or above (despite repeating it at least 2 times)
Chest pain
Changes in vision
Confusion
Severe headache
If you want more tips or to learn more, see the British Heart Foundation website.
13. Please enter your systolic (SYS) blood pressure reading. This is the top reading.
Answer
14. Please enter the diastolic (DIA) blood pressure reading. This is the lower reading. Note: This is not the pulse.
Answer
15. Do you know your weight?
Yes (Will be asked to provide weight in kilograms)
No
16. Please enter your weight in kilograms.
If you only know your weight in stone and pounds, please use this converter here.
Enter weight in kilograms
17. Do you know your height?
Yes (Will be asked for height in centimeters)
No
18. Please enter your height in metres.
For example, 1.67 metres.
Maximum allowed height is 3.00 metres.
If you only know your height in feet and inches, please use this converter here.
Enter height in metres
19. Is there anything else regarding the contraceptive pill that you would like us to know?
Type your answer here
When they have submitted their answers they will be thanked for completing the survey👇
If a smoker this page will also include:
Smoking cessation advice
Smoking leads to health problems such as cancer, heart disease and strokes. The benefits of stopping smoking include: better health, more money and cleaner air for those around you!
Do you want to stop smoking? Here is some advice on ways to quit smoking, local services and general tips: nhs.uk/smokefree
SNOMED codes saved to record
The codes added are in bold and italics
The following codes are also saved according to the patient's response:
"What is your smoking status?"
"Current smoker" - Current smoker
"Ex-smoker" - Ex-smoker
"Never smoked" - Never smoked
[if chose 'Current Smoker' above] Smoking: "How much do you smoke?"
"Trivial smoker (<1 cigarettes/day or equivalent)" - Trivial smoker (<1 cigarettes/day or equivalent)
"Light smoker (1-9 cigarettes/day or equivalent)" - Light smoker (1-9 cigarettes/day or equivalent)
"Moderate smoker (10-19 cigarettes/day or equivalent)" - Moderate smoker (10-19 cigarettes/day or equivalent)
"Heavy smoker (20-30 cigarettes/day or equivalent)" - Heavy smoker (20-30 cigarettes/day or equivalent)
"Very heavy smoker (40+ cigarettes/day or equivalent)" - Very heavy smoker (40+ cigarettes/day or equivalent)
Smoking cessation advice given - This code is added for anyone who says they are a current smoker. We display a standard short bit of smoking cessation advice with link to nhs.uk/smokefree.
Self reported systolic blood pressure (Concept ID: 1162737008 / CTV3 2469)
Self reported diastolic blood pressure (Concept ID: 1162735000 / CTV3 246A)
Weight - 162763007
Height - 162755006
BMI - 60621009